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Approximately one-third of patients undergoing general surgery will suffer some degree of AKI, and 3% of patients will develop a creatinine elevation greater than 2 mg/dL (176.8 mcmol/L) above baseline or require renal replacement therapy. The development of AKI in patients undergoing general surgery is an independent predictor of mortality, even if mild or if kidney dysfunction resolves. The mortality associated with the development of perioperative AKI that requires dialysis exceeds 50%. Risk factors associated with postoperative deterioration in kidney function are shown in Table 3–7. Several medications, including “renal-dose” dopamine, mannitol, N-acetylcysteine, and clonidine, have not been proved effective in clinical trials to preserve kidney function during the perioperative period and should not be used for this indication. Maintenance of adequate intravascular volume is likely to be the most effective method to reduce the risk of perioperative deterioration in kidney function. Exposure to renal-toxic agents, such as NSAIDs and intravenous contrast, should be minimized or avoided. ACE inhibitors and ARBs reduce renal perfusion and may increase the risk of perioperative AKI. Although firm evidence is lacking, it may be useful to temporarily discontinue these medications in patients at risk for perioperative AKI.

Table 3–7.Risk factors for the development of AKI after general surgery.1

Although the mortality rate for elective major surgery is low (1–4%) in patients with dialysis-dependent CKD, the risk for perioperative complications, including postoperative hyperkalemia, pneumonia, fluid overload, and bleeding, is substantially increased. Postoperative hyperkalemia requiring emergent hemodialysis has been reported to occur in 20–30% of these patients. Patients should undergo dialysis preoperatively within 24 hours before surgery, and their serum electrolyte levels should be measured just prior to surgery and monitored closely during the postoperative period.

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Gumbert  SD  et al. Perioperative acute kidney injury. Anesthesiology. 2020;132:180.
[PubMed: 31687986]  

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